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APWU Health Plan

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Introduction
Plain Language
Stop Health Care Fraud!
Section 1. Facts about this fee-for-service plan
Section 2. How we change for 2003
Section 3. How you get care
- Identification cards
- Where you get covered care
  - Covered providers
  - Covered facilities
- What you must do to get covered care
- How to Get Approval for
  - Your hospital stay
  - Other services
Section 4. Your costs for covered services
- Copayments
- Your catastrophic protection out-of-pocket maximum
- When government facilities bill us
- If we overpay you
- When you are age 65 or over and you do not have Medicare
- When you have Medicare
Section 5. High Option Benefits
- Overview
- Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
- Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
- Section 5 (c). Services provided by a hospital or other facility, and ambulance services
- Section 5 (d). Emergency services/accidents
- Section 5 (e). Mental health and substance abuse benefits
- Section 5 (f). Prescription drug benefits
- Section 5 (g). Special features
- Section 5 (h). Dental benefits
- Section 5 (i). Non-FEHB benefits available to Plan members
Section 6. Consumer-driven Option Benefits
- Overview
- Section 6 (a). In-network preventive care
- Section 6 (b). Personal Care Account (PCA)
- Section 6 (c). Traditional Health Coverage
- Section 6 (d). Health tools and resources
Section 7. General exclusions -- things we dont cover
Section 8. Filing a claim for covered services
Section 9. The disputed claims process
Section 10. Coordinating benefits with other coverage
- When you have other health coverage
- What is Medicare?
- Medicare managed care plan
- TRICARE AND CHAMPVA
- Workers Compensation
- Medicaid
- When other Government agencies are responsible for your care
- When others are responsible for injuries
Section 11. Definitions of terms we use in this brochure
Section 12. FEHB facts
- Coverage Information
- When you lose benefits
Long Term Care Insurance Is Still Available
Index
Summary of benefits - High Option
Summary of benefits - Consumer-driven Option
2003 Rates

Pages 1--96

Page 1


Dear Federal Employees Health Benefits Program Participant: I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care options best suited for themselves and their families. In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship. The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep health care affordable. Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your family. We suggest you also visit our web site at www.opm.gov/insure.
		Sincerely, Kay Coles James Director

APWU Health Plan http:// www. apwuhp. com
2003
A fee-for-service plan
and A consumer-driven plan

with preferred provider organizations

Sponsored and administered by: American Postal Workers Union, AFL-CIO
Who may enroll in this Plan: All Federal and Postal Service employees and
annuitants who are eligible to enroll in the FEHB Program may become members
of this Plan. To enroll, you must be, or must become, a member of the American
Postal Workers Union, AFL-CIO.

To become a member or associate member: All active Postal Service bargaining unit employees must be, or
must become, dues-paying members of the APWU, except where exempt by law. In item 1 of Part B of your
registration form, enter the number of your APWU Local immediately after the name of this Plan.

If you are a non-postal employee/ annuitant, you will automatically become an associate member of APWU
Health Plan upon enrollment in the APWU Health Plan.

Annuitants (retirees) may enroll in this Plan.
Membership dues: $35 per year for an associate membership. APWU will bill new associate members for the
annual dues when it receives notice of enrollment. APWU will also bill continuing associate members for the
annual membership. Active and retired Postal Service employee's membership dues vary by APWU local.

Enrollment codes for this Plan:
471 High Option -Self Only
472 High Option -Self and Family
474 Consumer-driven Option -Self Only
475 Consumer-driven Option -Self and Family

For changes in benefits
see page 9.

RI 71-004 1.
1 Page 2 3
2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.

By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is
required to protect the privacy of your personal medical information. OPM is also required to give you this notice to tell you how
OPM may use and give out (" disclose") your personal medical information held by OPM.

OPM will use and give out your personal medical information:
To you or someone who has the legal right to act for you (your personal representative),
To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected,
To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and
Where required by law.

OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:
To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim.
For OPM and the General Accounting Office when conducting audits.

OPM may use or give out your personal medical information for the following purposes under limited circumstances:
For Government healthcare oversight activities (such as fraud and abuse investigations),
For research studies that meet all privacy law requirements (such as for medical research or education), and
To avoid a serious and imminent threat to health or safety.

By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any
purpose that is not set out in this notice. You may take back (" revoke") your written permission at any time, except if OPM has
already acted based on your permission.

By law, you have the right to:
See and get a copy of your personal medical information held by OPM.
Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical

information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any information that you authorized

OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O. Box instead of your home address). 3.
3 Page 4 5

Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call
202-606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following
address:

Privacy Complaints
Office of Personnel Management
P. O. Box 707
Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the
Department of Health and Human Services.

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical
information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change. The
privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6

2003 APWU Health Plan 5 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of APWU Health Plan under our contract (CS 1370) with the Office of Personnel Management
(OPM), as authorized by the Federal Employees Health Benefits law. This plan is underwritten by the American Postal Workers
Union, AFL-CIO. The address for the APWU Health Plan administrative office is:

APWU Health Plan
P. O. Box 3279 Silver Spring, MD 20918

This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and Family
coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available before
January 1, 2003, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are
summarized on page 9. Rates are shown at the end of this brochure.

Plain Language
All FEHB brochures are written in plain language to make them responsive, accessible, and understandable to the public. For
instance,

Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member; "we" means APWU Health Plan

We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's "Rate Us"
feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may also write to OPM at the Office of
Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW Washington, DC 20415-3650

Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the
agency that employs you or from which you retired.

Protect Yourself From Fraud -Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services.
Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.

Carefully review explanations of benefits (EOBs) that you receive from us. 8.
8 Page 9 10
2003 APWU Health Plan 6 Introduction/ Plain Language/ Advisory
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:

Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 1-800/ 222-APWU and explain the situation.
If we do not resolve the issue:

Do not maintain as a family member on your policy:
your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
your child age 22 (unless he/ she is disabled and incapable of self support).
If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with OPM if you are retired.

You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan.

CALL --THE HEALTH CARE FRAUD HOTLINE
202-418-3300

OR WRITE TO:
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415 9.
9 Page 10 11

2003 APWU Health Plan 7 Section 1
Section 1. Facts about this fee-for-service plan
This Plan is a fee-for-service (FFS) plan. You can choose your own physicians, hospitals, and other health care providers.
We reimburse you or your provider for your covered services, usually based on a percentage of the amount we allow. The type and extent of covered services, and the amount we allow, may be different from other plans. Read brochures carefully.

We also have Preferred Provider Organizations (PPO):
Our fee-for-service plans offer services through PPO networks. When you use our network providers, you will receive covered
services at reduced cost. APWU Health Plan is solely responsible for the selection of PPO providers in your area. The PPO networks
for the High Option and the Consumer-driven Option are different.

High Option PPO Network: Contact APWU Health Plan at 800/ 222-APWU to request a High Option PPO directory. You can also
go to our web page, which you can reach through the FEHB website, www. opm. gov/ insure. If you need assistance in identifying a
participating provider or to verify their continued participation, call the Plan's PPO administrator for your state: Alliance PPO, Inc.
800/ 342-3289 for providers in the District of Columbia, Maryland, Virginia and West Virginia; Beech Street 800/ 923-3248 for providers in California, Florida, Georgia, Ohio, Oklahoma, Tennessee, Texas and Washington; MultiPlan 800/ 672-2140 for providers

in New Jersey and New York; MedNet 800/ 556-1144 for providers in Maine; PreferredOne 800/ 451-9597 for providers in Minnesota;
V. I. Equicare 340/ 774-5779 for providers in the U. S. Virgin Islands; or First Health 800/ 447-1704 for all other states. For mental
conditions/ substance abuse providers (all states), call ValueOptions toll-free 888/ 700-7965.

Consumer-driven Option PPO Network: To obtain a PPO directory or if you need assistance identifying a participating provider or
to verify their continued participation, call the Plan's Consumer-driven Option administrator, Definity Health of St. Louis Park, MN,
at 866/ 833-3463 or you can go to their web page, www. definityhealth. com, User ID: APWUHP, Password: HPINFO for a full
nationwide online provider directory.

The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider. Provider networks may be more extensive in some areas than others. We cannot guarantee the availability of every specialty in all areas. If no
PPO provider is available, or you do not use a PPO provider, the standard non-PPO benefits apply.
How we pay providers
PPO Providers: Allowable benefits are based upon charges and discounts which we or our PPO administrators have negotiated with
participating providers. PPO provider charges are always within our plan allowance.

Non-PPO providers: We determine our allowance for covered charges by using health care charge data prepared by the Health
Insurance Association of America (HIAA) or other credible sources, including our own data, when necessary. We apply this charge
data under the High Option at the 70 th percentile and under the Consumer-driven Option at the 80 th percentile.

Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our
networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types of information that we must
make available to you. Some of the required information is listed below.

Spectera/ CARE Programs, is the major subcontractor performing hospital precertification, continued stay review and case management for the High Option. The American Accreditation HealthCare Commission/ URAC has accredited them for Health

Utilization Management since 1993.
PreferredOne Administrative Services, Inc. performs hospital precertification, continued stay review and case management for High Option members in the State of Minnesota only. The American Accreditation HealthCare Commission/ URAC has

accredited them for Health Utilization Management since 1993, Health Network w/ Credentialing and Health Plan since 2000.
ValueOptions performs hospital precertification, continued stay review and outpatient prior authorization for mental health/ substance abuse services. The American Accreditation HealthCare Commission/ URAC has accredited them for Health

Utilization Management since 1992. 10.
10 Page 11 12

2003 APWU Health Plan 8 Section 1
The American Postal Workers Union Health Plan is a not-for-profit Voluntary Employee's Beneficiary Association (VEBA) formed in 1972.
We meet applicable State and Federal licensing and accreditation requirements for fiscal solvency, confidentiality and transfer of medical records.
If you want more information about us, call 800/ 222-APWU, or write to APWU Health Plan, P. O. Box 3279, Silver Spring, MD
20918. You may also contact us by fax at 301/ 622-5712 or visit our website at www. apwuhp. com. 11.
11 Page 12 13

2003 APWU Health Plan 9 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Sections 5 and 6 Benefits.
Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not
change benefits.

Program-wide changes
A Notice of the Office of Personnel Management's Privacy Practices is included.
A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.
Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB Program enrollment.

Program information on Medicare is revised.
The Medically Underserved section is revised.
By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.

Changes to this Plan
High Option
Your share of the Postal premium will increase by 3.8% for Self Only or 2.1% for Self & Family.
Your share of the non-Postal premium will increase by 6.6% for Self Only or 6.1% for Self and Family.
We now cover a colonoscopy once every 10 years from age 50 as part of our coverage for colorectal cancer screening.
We now cover one Double Contrast Barium Enema (DCBE) every 5 years from age 50 as part of our coverage for colorectal cancer screening.

We now cover one fasting lipoprotein profile every 5 years for adults 20 or over.
If you are using non-PPO providers, your catastrophic protection out-of-pocket maximum is $8,000 for either a Self Only or a Self and Family enrollment. The limit was previously $6,000.

We now limit benefits for physical, speech and occupational therapy to a maximum of 60 combined visits per calendar year. There was previously no limit to the number of visits.
We now limit home health services to 25 visits for skilled nursing care per calendar year. There was previously no limit to the number of visits.
We have clarified that there is a $5 minimum applicable for brand name drugs obtained from a network pharmacy or network mail order.
We removed the exclusion for coverage of services for illness or injury resulting from an act of war within the United States, its territories or possessions.

New Consumer-driven Option
We have added a new option called Consumer-driven. -You receive a Personal Care Account (PCA) of $1,000 for Self Only or $2,000 for Self and Family which you use first to pay
100% of covered expenses, including some dental/ vision care services, up to specified maximums. Unused PCA benefits may be rolled over to increase your PCA in the following year( s).
-In-network preventive care services are paid at 100% and do not count against your Personal Care Account.
-If you exhaust your PCA, you must pay your Member Responsibility before your Traditional Health Coverage begins
-You receive access to important health tools and resources to help you effectively shop for and manage your health care and
wellness services.
-Please review this brochure, including Consumer-driven Option Benefits in Sections 6( a), 6( b), 6( c) and 6( d) to understand this
new option. If you have any questions about this new option, you may call us at 800/ 222-APWU or call our Consumer- driven
Option administrator, Definity Health, at 866/ 833-3463. 12.
12 Page 13 14

2003 APWU Health Plan 10 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use
your copy of the Health Benefits Election Form, SF-2809, your health benefits
enrollment confirmation (for annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, contact us as follows:

High Option: Call us at 800/ 222-APWU or write to us at P. O. Box 3279, Silver Spring, MD 20918 or through our website: www. apwuhp. com.
Consumer-driven Option: Call Definity Health at 866/ 833-3463 or request replacement cards through the website at www. definityhealth. com.

Where you get covered care You can get care from any "covered provider" or "covered facility." How much we pay and you pay depends on the type of covered provider or facility you use. If you use
our preferred providers, you will pay less.

Covered providers We consider the following to be covered providers when they perform services within the scope of their license or certification:

1. Doctor A licensed doctor of medicine (M. D.), a licensed doctor of osteopathy
(D. O.), a licensed doctor of podiatry (D. P. M.), or, for certain specified services covered by this Plan, a licensed dentist, licensed chiropractor, or licensed

clinical psychologist practicing within the scope of the license.
2. Alternate Provider Alternate providers are covered when performing certain
specified services covered by this Plan and when such treatment is within the
scope of the provider's license. Alternate providers are limited to licensed
physical, occupational and speech therapists; licensed physician's assistants;
Registered Nurses (R. N.); Licensed Practical Nurses (L. P. N.); Licensed
Vocational Nurses (L. V. N.); and Certified Registered Nurse Anesthetists
(C. R. N. A.).

3. Other covered providers include a qualified clinical psychologist, clinical social
worker, optometrist, audiologist, nurse midwife, nurse practitioner/ clinical specialist, and nursing school administered clinic. For purposes of this FEHB

brochure, the term "doctor" includes all of these providers when the services are
performed within the scope of their license or certification.

Medically underserved areas. Note: We cover any licensed medical practitioner
for any covered service performed within the scope of that license in states OPM
determines are "medically underserved." For 2003, the states are: Alabama, Idaho,
Kentucky, Louisiana, Maine, Mississippi, Missouri, Montana, New Mexico,
North Dakota, South Carolina, South Dakota, Texas, Utah, West Virginia, and
Wyoming.

Covered facilities Covered facilities include:
Freestanding ambulatory facility

An out-of-hospital facility such as a medical, cancer, dialysis, or surgical center or
clinic, and licensed outpatient facilities accredited by the Joint Commission on
Accreditation of Healthcare Organizations for treatment of substance abuse. 13.
13 Page 14 15
2003 APWU Health Plan 11 Section 3
Covered facilities (Continued) Hospital
1) An institution which is accredited as a hospital under the Hospital Accreditation
Program of the Joint Commission on Accreditation of Healthcare Organizations,
or

2) Any other institution which is operated pursuant to law, under the supervision of
a staff of doctors and twenty-four hour a day nursing service, and which is primarily engaged in providing:

a) general inpatient care and treatment of sick and injured persons through
medical, diagnostic and major surgical facilities, all of which must be
provided on its premises or under its control, or

b) specialized inpatient medical care and treatment of sick or injured persons through medical and diagnostic facilities (including X-ray and laboratory)

on its premises, under its control, or through a written agreement with a
hospital (as defined above) or with a specialized provider of those facilities.

The term "hospital" shall not include a skilled nursing facility, a convalescent
nursing home or institution or part thereof which 1) is used principally as a
convalescent facility, rest facility, residential treatment center, nursing facility or facility for the aged or 2) furnishes primarily domiciliary or custodial care, including

training in the routines of daily living.

What you must do to
get covered care

It depends on the kind of care you want to receive. You can go to any provider you
want, but we must approve some care in advance.

Transitional care Specialty care: If you have a chronic or disabling condition and
lose access to your specialist because we drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan, or

lose access to your PPO specialist because we terminate our contract with your specialist for other than cause,

you may be able to continue seeing your specialist and receiving any PPO benefits for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the
Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access to your
specialist based on the above circumstances, you can continue to see your specialist and
any PPO benefits continue until the end of your postpartum care, even if it is beyond the
90 days.

Hospital care We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our High Option begins, call our customer
service department immediately at 800/ 222-APWU. For the Consumer-driven Option,
please call Definity Health at 866/ 833-3463.

If you changed from another FEHB plan to us, your former plan will pay for the hospital
stay until:

You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92nd day after you become a member of this Plan, whichever happens first

These provisions apply only to the benefits of the hospitalized person. 14.
14 Page 15 16
2003 APWU Health Plan 12 Section 3
How to Get Approval for
Your hospital stay Precertification is the process by which prior to your inpatient hospital admission we evaluate the medical necessity of your proposed stay and the number of days required
to treat your condition. Unless we are misled by the information given to us, we won't
change our decision on medical necessity.

In most cases, your physician or hospital will take care of precertification. Because you
are still responsible for ensuring that we are asked to precertify your care, you should
always ask your physician or hospital whether they have contacted us.

Warning We will reduce our benefits for the inpatient hospital stay by $500 if no one contacts us for precertification. If the stay is not medically necessary, we will not pay any benefits.

How to precertify an
admission High Option: You, your representative, your doctor, or your hospital must call Spectera/ Care at 800/ 580-8771 at least 48 hours before admission. In Minnesota,
call PreferredOne at 800/ 451-9597 to precertify. These numbers are available 24
hours every day.
Consumer-driven Option: You, your representative, your doctor, or your hospital must call Definity Health at 866/ 333-4648 at least 48 hours before admission. This

number is available 24 hours every day.
If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your

representative, the doctor, or the hospital must telephone the above number 48 hours
following the day of the emergency admission, even if you have been discharged
from the hospital.
Provide the following information:
-Enrollee's name and Plan identification number
-Patient's name, birth date, and phone number
-Reason for hospitalization, proposed treatment, or surgery -
Name and phone number of admitting doctor
-Name of hospital or facility; and
-Number of planned days of confinement
We will then tell the doctor and/ or hospital the number of approved inpatient days and we will send written confirmation of our decision to you, your doctor, and the

hospital.
Maternity care You do not need to precertify a maternity admission for a routine delivery. However, if
your medical condition requires you to stay more than 48 hours after a vaginal delivery
or 96 hours after a cesarean section, then your physician or the hospital must contact us
for precertification of additional days. Further, if your baby stays after you are
discharged, then your physician or the hospital must contact us for precertification of additional days for your baby.

If your hospital stay
needs to be extended:
High Option: If your hospital stay --including for maternity care --needs to be
extended, you, your representative, your doctor or the hospital must ask us to approve the
additional days by calling Spectera/ Care at 800/ 580-8771 or in Minnesota, call
PreferredOne at 800/ 451-9597.

Consumer-driven Option: If your hospital stay including for maternity care -needs
to be extended, you, your representative, your doctor or the hospital must ask us to
approve the additional days by calling Definity Health at 866/ 333-4648.

What happens when you
do not follow the
precertification rules

If no one contacted us, we will decide whether the hospital stay was medically necessary.
-If we determine that the stay was medically necessary, we will pay the inpatient charges, less the $500 penalty. 15.
15 Page 16 17
2003 APWU Health Plan 13 Section 3
-If we determine that it was not medically necessary for you to be an inpatient, we will not pay inpatient hospital benefits. We will only pay for any covered
medical supplies and services that are otherwise payable on an outpatient basis.
If we denied the precertification request, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise

payable on an outpatient basis.
When we precertified the admission but you remained in the hospital beyond the number of days we approved and did not get the additional days precertified, then:

-for the part of the admission that was medically necessary, we will pay inpatient benefits, but

-for the part of the admission that was not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and will
not pay inpatient benefits.

Exceptions You do not need precertification in these cases:
You are admitted to a hospital outside the United States and Puerto Rico.
You have another group health insurance policy that is the primary payer for the hospital stay.

Your Medicare Part A is the primary payer for the hospital stay. Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare
lifetime reserve days, then we will become the primary payer and you do need precertification.

Other services Some services require prior approval (High Option) and some require pre-notification (Consumer-driven Option):
High Option: Call Spectera/ Care at 800/ 580-8771 if you need any of the services listed
below:

Consumer-driven Option: Call Definity Health at 866/ 333-4648 if you need any of the
services listed below:

Prior approval/ pre-notification is required for organ transplantation. Call before your first evaluation as a potential candidate.

Prior approval/ pre-notification is required for surgical procedures which may be cosmetic in nature such as eyelid surgery (blepharoplasty) or varicose vein surgery
(sclerotherapy).
Prior approval/ pre-notification is required for recognized surgery for morbid obesity or for organic impotence.

Prior approval/ pre-notification is required for home health care such as nursing visits, infusion therapy, growth hormone therapy (GHT), rehabilitative therapy
(physical, occupational or speech therapy) and pulmonary rehabilitation programs.
Prior approval/ pre-notification is required for durable medical equipment such as wheelchairs, oxygen equipment and supplies, artificial limbs and braces.

Prior approval is also required for mental health and substance abuse benefits, inpatient
or outpatient, in-network or out-of-network. Under the High Option and the Consumer-driven
Option, call ValueOptions at 888/ 700-7965. 16.
16 Page 17 18
2003 APWU Health Plan 14 Section 4
Section 4. Your costs for covered services
This is what you will pay out-of-pocket for your covered care:
Copayments High Option: A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: Under the High Option, when you see your PPO physician you pay a
copayment of $15 per visit.

Consumer-driven Option: There are no copayments under the Consumer-driven
Option.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count
toward any deductible.
High Option
If you use PPO providers, the calendar year deductible is $275 per person. Under a family enrollment, the deductible is satisfied for all family members when the

combined covered expenses applied to the calendar year deductible for family
members reach $550. If you use non-PPO providers, your calendar year deductible
increases to a maximum of $350 per person ($ 700 per family). Whether or not you
use PPO providers, your calendar year deductible will not exceed $350 per person
($ 700 per family).
We also have a separate deductible for mental health and substance abuse benefits. The in-network deductible is $275 per person. Under a family enrollment, this

deductible is satisfied for all family members when the combined in-network
covered expenses applied to this deductible for all family members reach $550. The out-of-network deductible is $750 per person each calendar year with no family

maximum.
Note: If you change plans during Open Season, you do not have to start a new
deductible under your old plan between January 1 and the effective date of your new
plan. If you change plans at another time during the year, you must begin a new
deductible under your new plan.

And, if you change from Self and Family to Self Only, or from Self Only to Self and
Family during the year, we will credit the amount of covered expenses already applied
toward the deductible of your old enrollment to the deductible of your new enrollment.
However, if you change from High Option to Consumer-driven Option, or from Consumer-driven Option to High Option, during the year, expenses incurred as of the effective date of

the option change are subject to the benefit provisions of your new option.
Consumer-driven Option: There is no calendar year deductible under the Consumer-driven
Option. Also, there is no separate deductible for mental health and substance
abuse benefits under the Consumer-driven Option.

Coinsurance High Option: Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance doesn't begin until you meet your deductible (High Option) or

your Member Responsibility (Consumer-driven Option).
Example: You pay 30% of our allowance for office visits to a non-PPO physician.
Note: If your provider routinely waives (does not require you to pay) your copayments,
deductibles, or coinsurance, the provider is misstating the fee and may be violating the law. In this case, when we calculate our share, we will reduce the provider's fee by the

amount waived. 17.
17 Page 18 19

2003 APWU Health Plan 15 Section 4
For example, if your physician ordinarily charges $100 for a service but routinely waives
your 30% coinsurance, the actual charge is $70. We will pay $49 (70% of the actual
charge of $70).

Consumer-driven Option: Coinsurance is the percentage of our allowance that you
must pay for your care after you have used up your Personal Care Account (PCA) and
paid your Member Responsibility.

Member Responsibility High Option: Does not apply.

Consumer-driven Option: Your Member Responsibility is your bridge between your
Personal Care Account (PCA) and your Traditional Health Coverage. After you have
exhausted your PCA, you must pay your Member Responsibility before your Traditional
Health Coverage begins. Your Member Responsibility is generally $600 for a Self Only enrollment or $1,200 for a Self and Family enrollment. Your Member Responsibility in

subsequent years may be reduced by rolling over any unused portion of your Personal
Care Account remaining at the end of the calendar year( s).

Differences between our allowance and the bill High Option: Our "Plan allowance" is the amount we use to calculate our payment for covered services. Fee-for-service plans arrive at their allowances in different ways, so
their allowances vary. For more information about how we determine our Plan
allowance, see the definition of Plan allowance in Section 11.

Often, the provider's bill is more than a fee-for-service plan's allowance. Whether or not
you have to pay the difference between our allowance and the bill will depend on the provider you use.

PPO providers agree to limit what they will bill you. Because of that, when you use a preferred provider, your share of covered charges consists only of your
deductible and coinsurance or copayment. Here is an example about coinsurance:
You see a PPO physician who charges $150, but our allowance is $100. If you have
met your deductible, you are only responsible for your coinsurance. That is, you pay
just --10% of our $100 allowance ($ 10). Because of the agreement, your PPO
physician will not bill you for the $50 difference between our allowance and his bill.

Non-PPO providers, on the other hand, have no agreement to limit what they will bill you. When you use a non-PPO provider, you will pay your deductible and

coinsurance --plus any difference between our allowance and charges on the bill.
Here is an example: You see a non-PPO physician who charges $150 and our allowance is again $100. Because you've met your deductible, you are responsible

for your coinsurance, so you pay 30% of our $100 allowance ($ 30). Plus, because
there is no agreement between the non-PPO physician and us, he can bill you for the
$50 difference between our allowance and his bill.

The following table illustrates the examples of how much you have to pay out-of-pocket
for services from a PPO physician vs. a non-PPO physician. The table uses our example
of a service for which the physician charges $150 and our allowance is $100. The table
shows the amount you pay if you have met your calendar year deductible.

EXAMPLE PPO physician Non-PPO physician
Physician's charge $150 $150
Our allowance We set it at: 100 We set it at: 100
We pay 90% of our allowance: 90 70% of our allowance: 70
You owe: Coinsurance 10% of our allowance: 10 30% of our allowance: 30
+Difference up to
charge?
No: 0 Yes: 50

TOTAL YOU PAY $10 $80 18.
18 Page 19 20

2003 APWU Health Plan 16 Section 4
Consumer-driven Option:
PPO providers agree to accept our plan allowance so if you use a PPO Provider, you never have to worry about paying the difference between the plan allowance

and the billed amount for covered services. If your covered expenses are being
paid out of your Personal Care Account or if you are receiving in-network covered
preventive services, the plan will pay 100%. If you have exhausted your Personal Care Account, you will be responsible for paying your Member Responsibility and

also coinsurance under the Traditional Health Coverage.
Non PPO Providers: If you use a non-PPO provider, you will have to pay the difference between the plan allowance and the billed amount only if you use up

your Personal Care Account for the year. Note that it usually makes sense to use
PPO providers because it will make your Personal Care Account go much further
since money left in your Personal Care Account can be rolled over to be used in the
next year.

Your catastrophic protection
out-of-pocket maximum for
deductibles, coinsurance,
copayments, and Member
Responsibility

There is a limit to the amount you must pay out-of-pocket for coinsurance for the year
for certain charges. When you have reached this limit, you pay no coinsurance for
covered services for the remainder of the calendar year.

High Option:
PPO benefit: Your out-of-pocket maximum is $4,000 for either a Self Only or a Self and
Family enrollment if you are using PPO providers.

Non-PPO benefit: Your out-of-pocket maximum is $8,000 for either a Self Only or a
Self and Family enrollment if you are using non-PPO providers.

Out-of-pocket expenses for the purposes of this benefit are:
The 10% you pay for PPO Inpatient hospital charges, Surgical, Maternity and Diagnostic and treatment services

The 30% you pay for non-PPO Inpatient hospital charges, Surgical, Maternity and Diagnostic and treatment services; and
The copayment of $15 for outpatient visits to PPO physicians
The following cannot be included in the accumulation of out-of-pocket expenses:
Expenses in excess of our allowance or maximum benefit limitations
Expenses for out-of-network mental health or substance abuse or dental care
Any amounts you pay because benefits have been reduced for non-compliance with this Plan's cost containment requirements (see pages 12, 13 and 14)

Covered expenses applied to the $275 or $350 calendar year deductibles
Covered expenses applied to the $275 deductible for in-network mental health or substance abuse care

The $200 per admission deductible for non-PPO Inpatient hospital charges
Expenses for prescription drugs
Expenses in excess of visit maximums for physical, occupational and speech therapy (see page 25)

Expenses incurred in excess of the $90 per day provided under home nursing care (see page 27); and
Expenses in excess of hospice care and preventive care maximums 19.
19 Page 20 21

2003 APWU Health Plan 17 Section 4
Your catastrophic protection
out-of-pocket maximum for
deductibles, coinsurance,
copayments, and Member Responsibility
(continued)

Consumer-driven Option:
If you have exceeded your Personal Care Account and met your Member Responsibility
the following would apply:

In-network benefit: Your out-of-pocket maximum is $4, 500 for either a Self Only or a
Self and Family enrollment if you are using network providers.

Out-of-network benefit: Your out-of-pocket maximum is $9,000 for either a Self Only
or a Self and Family enrollment if your are using out-of-network providers.

Out-of-pocket expenses for the purposes of this benefit are:
The 15% you pay for in-network Inpatient and outpatient hospital charges, Surgical, Medical, Maternity and Emergency services under the Traditional Health Coverage

The 40% you pay for out-of-network Inpatient and outpatient hospital charges, Surgical, Medical, Maternity and Emergency services under the Traditional Health
Coverage
The following cannot be included in the accumulation of out-of-pocket expenses:
Any expenses paid by the Plan under your Personal Care Account
Any expenses paid by the Plan under your In-network Preventive Care benefit
Any expenses you must pay under your Member Responsibility
Expenses in excess of our allowance or maximum benefit limitations or expenses not covered under the Traditional Health Coverage

Expenses for out-of-network mental health or substance abuse care
The 25% you pay for prescription drugs under your Traditional Health Coverage
Dental care or vision care expenses above the limitations provided under your Personal Care Account

Any amounts you pay because benefits have been reduced for non- compliance with this Plan's cost containment requirements (see pages 12, 13, 14 and 15)
Expenses in excess of hospice care maximums
Carryover If you enrolled in our Plan during Open Season and your effective date is after January 1,
your previous plan will be responsible for any medical care you received before your
coverage in our Plan began. The old plan will pay your covered costs under this year's benefits since benefit changes start on January 1. If you did not meet your out-of-pocket

maximum under your old plan last year, your covered out-of-pocket expenses will be
applied to that maximum. If you did meet that maximum, your old plan's catastrophic
protection benefit will continue to apply until your effective date in our Plan.

When government facilities
bill us

Facilities of the Department of Veterans Affairs, the Department of Defense, and the
Indian Health Service are entitled to seek reimbursement from us for certain services and
supplies they provide to you or a family member. They may not seek more than their
governing laws allow.

If we overpay you We will make diligent efforts to recover benefit payments we made in error but in good faith. We may reduce subsequent benefit payments to offset overpayments. We will
generally first seek recovery from the provider if we paid the provider directly, or from
the person (covered family member, guardian, custodial parent, etc.) to whom we sent
our payment. 20.
20 Page 21 22
2003 APWU Health Plan 18 Section 4
When you are age 65 or over and you do not have Medicare
Under the FEHB law, we must limit our payments for those benefits you would be entitled to if you had Medicare. Your physician
and hospital must follow Medicare rules and cannot bill you for more than they could bill you if you had Medicare. The following
chart has more information about the limits.

If you
are age 65 or over, and
do not have Medicare Part A, Part B, or both; and
have this Plan as an annuitant or as a former spouse, or as a family member of an annuitant or former spouse; and
are not employed in a position that gives FEHB coverage. (Your employing office can tell you if this applies.)

Then, for your inpatient hospital care,
the law requires us to base our payment on an amount --the "equivalent Medicare amount" --set by Medicare's rules for what Medicare would pay, not on the actual charge;

you are responsible for your applicable deductibles, coinsurance, or copayments you owe under this Plan;
you are not responsible for any charges greater than the equivalent Medicare amount; we will show that amount on the explanation of benefits (EOB) form that we send you; and

the law prohibits a hospital from collecting more than the Medicare equivalent amount.
And, for your physician care, the law requires us to base our payment and your coinsurance on
an amount set by Medicare and called the "Medicare approved amount," or
the actual charge if it is lower than the Medicare approved amount.

If your physician Then you are responsible for

Participates with Medicare or accepts
Medicare assignment for the claim and
is a member of our PPO network,

your deductibles, coinsurance, and copayments;

Participates with Medicare and is not in our PPO network, your deductibles, coinsurance, copayments, and any balance up to the Medicare approved amount;
Does not participate with Medicare, your deductibles, coinsurance, copayments, and any
balance up to 115% of the Medicare approved amount

It is generally to your financial advantage to use a physician who participates with Medicare. Such physicians are permitted to
collect only up to the Medicare approved amount.

Our explanation of benefits (EOB) form will tell you how much the physician or hospital can collect from you. If your physician or
hospital tries to collect more than allowed by law, ask the physician or hospital to reduce the charges. If you have paid more than
allowed, ask for a refund. If you need further assistance, call us. 21.
21 Page 22 23

2003 APWU Health Plan 19 Section 4
When you have the Original
Medicare Plan
(Part A, Part B, or both)

We limit our payment to an amount that supplements the benefits that Medicare would
pay under Medicare Part A (Hospital insurance) and Medicare Part B (Medical
insurance), regardless of whether Medicare pays. Note: We pay our regular benefits
for emergency services to an institutional provider, such as a hospital, that does not
participate with Medicare and is not reimbursed by Medicare.

If you are covered by Medicare Part B and it is primary, your out-of-pocket costs for services that both Medicare Part B and we cover depend on whether your physician
accepts Medicare assignment for the claim.
High Option: If your physician accepts Medicare assignment, then you pay nothing for covered charges.

Consumer-driven Option: If your physician accepts Medicare assignment, then you pay nothing if you have unused benefits available under your Personal Care
Account to pay the difference between the Medicare approved amount and
Medicare's payment. If your PCA is exhausted, you must pay either this full
difference under your Member Responsibility or the lesser of your coinsurance or
the full difference if your Member Responsibility has been met.
If your physician does not accept Medicare assignment, then you pay the difference between our payment combined with Medicare's payment and the charge.

Note: The physician who does not accept Medicare assignment may not bill you for
more than 115% of the amount Medicare bases its payment on, called the "limiting
charge." The Medicare Summary Notice (MSN) that Medicare will send you will have
more information about the limiting charge. If your physician tries to collect more than
allowed by law, ask the physician to reduce the charges. If the physician does not,
report the physician to your Medicare carrier who sent you the MSN form. Call us if
you need further assistance.

Please see Section 10, Coordinating benefits with other coverage, for more
information about how we coordinate benefits with Medicare. 22.
22 Page 23 24

2003 APWU Health Plan 20 Section 5
HIGH OPTION
Section 5. High Option Benefits --OVERVIEW
(See page 9 for how our benefits changed this year and page 91 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of
each subsection. Also read the General Exclusions in Section 7; they apply to the benefits in the following subsections. To obtain
claim forms, claims filing advice, or more information about our benefits, contact us at 800/ 222-APWU or at our website at
www. apwuhp. com

(a) Medical services and supplies provided by physicians and other health care professionals..................................................... 21- 28

Diagnostic and treatment services
Lab, X-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical and occupational therapy
Speech therapy

Hearing services (testing, treatment, and
supplies)
Vision services (testing, treatment, and
supplies)
Foot care
Orthopedic and prosthetic devices
Durable medical equipment (DME)
Home health services
Chiropractic
Alternative treatments
Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals.................................................. 29-33
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery

Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services .............................................................................. 34-36
Inpatient hospital
Outpatient hospital or ambulatory surgical center
Extended care benefits/ Skilled nursing care facility
benefits

Hospice care
Ambulance

(d) Emergency services/ Accidents ............................................................................................................................................. 37-38
Accidental injury
Medical emergency
Ambulance

(h) Dental benefits ......................................................................................................................................................................... 44

(i) Non-FEHB benefits available to Plan members ......................................................................................................................... 45
SUMMARY OF BENEFITS -HIGH OPTION................................................................................................................................... 91 23.
23 Page 24 25

2003 APWU Health Plan 21 Section 5( a)
HIGH OPTION
Section 5 (a). Medical services and supplies provided by physicians
and other health care professionals

I M
P O
R T
A N
T

Here are some important things you should keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

The calendar year deductible is: PPO -$275 per person ($ 550 per family); Non-PPO -$350 per person ($ 700 per family). The calendar year deductible applies to almost all benefits in this
Section. We added "( No deductible)" to show when the calendar year deductible does not apply.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

When you use a PPO hospital, keep in mind that the professionals who provide services to you in the hospital, such as radiologists, emergency room physicians, anesthesiologists, and pathologists,
may not all be preferred providers. If they are not, they will be paid by this Plan as non-PPO
providers.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 10

about coordinating benefits with other coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You Pay After the calendar year deductible
NOTE: The calendar year deductible applies to almost all benefits in this Section. We say "( No deductible)" when it does not apply.
Diagnostic and treatment services
Professional services of physicians
In physician's office
PPO: $15 copayment (No deductible)
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility
Initial examination of a newborn child covered under a family
enrollment
Second surgical opinion
At home

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

Not covered: Routine physical checkups and related tests All charges 24.
24 Page 25 26
2003 APWU Health Plan 22 Section 5( a)
HIGH OPTION
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

Note: If your PPO provider uses a non-PPO
lab or radiologist, we will pay non-PPO benefits for any lab and X-ray charges.

Not covered: Professional fees for automated lab tests All charges
Preventive care, adult
Routine screenings, limited to:
Total Blood Cholesterol once annually
Fasting lipoprotein profile, once every 5 years for adults age 20 or over
Chlamydial infection
Colorectal Cancer Screening, including -
Fecal occult blood test, once annually, ages 40 and older
-Sigmoidoscopy, screening every five years starting at age 50
-Colonoscopy, once every 10 years starting at age 50
-Double Contrast Barium Enema (DCBE), once every 5 years starting at age 50

Routine Prostate Specific Antigen (PSA) test one annually for men age 40 and older
Routine pap test, one annually, women age 18 and older

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

Routine mammogram covered for women age 35 and older, as follows:
From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and the billed amount

Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and over (except as provided for under Childhood immunizations)

Influenza vaccine, annually
Pneumococcal vaccine, age 65 and older

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

Not covered:
Adult immunizations other than those listed above
Office visit associated with preventive care

All charges 25.
25 Page 26 27

2003 APWU Health Plan 23 Section 5( a)
HIGH OPTION
Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Pediatrics up to age 22

Examinations, limited to:
-Well-child care charges for physical examinations and laboratory tests through age 12

-Examination for amblyopia and strabismus-limited to one screening examination (age 2 through 6)

PPO: Nothing (No deductible)
Non-PPO: Any difference between the Plan
allowance and the billed charge (No deductible)

PPO: Nothing (No deductible)
Non-PPO: Any difference between the Plan
allowance and the billed charge and any
amount above $250 per child (ages 0
through 3) each year and any amount above $150 per child (ages 4 through 12) each

year (No deductible)
Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care

Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see pages 12 and 13 for other circumstances, such as extended stays for you or

your baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will cover an

extended stay if medically necessary, but you, your representative,
your doctor, or your hospital must precertify.
We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other

care of an infant who requires non-routine treatment if we cover the
infant under a Self and Family enrollment. We cover circumcision
of a covered newborn under Surgical benefits. See Surgery benefits (Section 5b).

We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital Benefits (Section 5c) and
Surgery Benefits (Section 5b).

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

Not covered: Amniocentesis if for diagnosing multiple births All charges
Family planning
A range of voluntary family planning services, limited to:
Voluntary sterilization (See Surgical procedures Section 5( b))
Surgically implanted contraceptives
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms

Note: We cover oral contraceptives under the prescription drug benefit.

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

Not covered: Reversal of voluntary surgical sterilization and genetic
counseling
All charges 26.
26 Page 27 28

2003 APWU Health Plan 24 Section 5( a)
HIGH OPTION
Infertility services You pay
Diagnosis and treatment of infertility, except as shown in Not covered. PPO: 10% of the Plan allowance and any
amount over $2,500

Non-PPO: 30% of the Plan allowance, any
difference between our allowance and the
billed amount and any amount over $2,500

Not covered:
Infertility services after voluntary sterilization
Assisted reproductive technology (ART) procedures, such as:
-artificial insemination (all procedures) -
in vitro fertilization
-embryo transfer and GIFT
-intravaginal insemination (IVI)
-intracervical insemination (ICI)
-intrauterine insemination (IUI)
Services and supplies related to ART procedures
Cost of donor sperm
Cost of donor egg

All charges

Allergy care
Testing and treatment, including materials (such as allergy serum)
Allergy injections
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

Not covered: Provocative food testing and sublingual allergy
desensitization
All charges

Treatment therapies
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants is limited to those transplants listed on page 32.

Dialysis hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy
Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit.
Note: We only cover IV/ Infusion therapy and GHT when we
preauthorize the treatment. Call Spectera/ Care at 800/ 580-8771 for
preauthorization. Spectera/ Care will ask you to submit information that
establishes that GHT is medically necessary. You should ask for
preauthorization before you begin treatment. If you do not ask or if we
determine GHT is not medically necessary, we will not cover GHT or
related services and supplies. See Services requiring our prior approval in Section 3.

Respiratory and inhalation therapies

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and the billed amount 27.
27 Page 28 29
2003 APWU Health Plan 25 Section 5( a)
HIGH OPTION
Physical and occupational therapies You pay
Physical therapy and occupational therapy provided by a licensed
registered therapist up to a combined 60 visits per calendar year.

Note: Preauthorization of rehabilitative therapies is required. Call
Spectera/ Care at 800/ 580-8771 for preauthorization.

Note: We only cover physical and occupational therapy to restore bodily
function when there has been a total or partial loss of bodily function due
to illness or injury and when a physician:

1) Orders the care
2) Identifies the specific professional skills the patient requires and the
medical necessity for skilled services; and
3) Indicates the length of time the services are needed

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

Not covered:
Maintenance therapies
Exercise programs
Physical and occupational therapies without preauthorization

All charges

Speech therapy
Speech therapy where medically necessary and provided by a licensed therapist

Note: Preauthorization of speech therapy is required. Call Spectera/ Care
at 800/ 580-8771 for preauthorization.

Note: Speech therapy is combined with 60 visits per year for the services
of physical therapy and/ or occupational therapy (see above).

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

Hearing services (testing, treatment, and supplies)
Audiologist to diagnose a hearing problem PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

Not covered:
Hearing aids, testing and examinations for them
All charges

Vision services (testing, treatment, and supplies)
Internal (implant) ocular lenses and/ or the first contact lenses required to correct an impairment caused by accident or illness. The

services of an optometrist are limited to the testing, evaluation and
fitting of the first contact lenses required to correct an impairment
caused by accident or illness.

Note: See Preventive care, children for eye exams for children

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

Not covered:
Eyeglasses or contact lenses and examinations for them
Eye exercises and visual training
Radial keratotomy and other refractive surgery

All charges 28.
28 Page 29 30

2003 APWU Health Plan 26 Section 5( a)
HIGH OPTION
Foot care
Routine foot care when you are under active treatment for a metabolic or
peripheral vascular disease, such as diabetes

See Orthopedic and prosthetic devices for information on podiatric shoe
inserts

PPO: $15 copayment for the office visit (No
deductible) plus 10% of the Plan allowance
for other services performed during the visit

Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

Not covered:
Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot,

except as stated above
Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the

treatment is by open cutting surgery)

All charges

Orthopedic and prosthetic devices
Artificial limbs and eyes; stump hose
Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy

Leg, arm, neck and back braces
Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant following
mastectomy. Note: See Section 5( b) for coverage of the surgery to
insert the device.

Note: We recommend preauthorization of orthopedic and prosthetic
devices. Call Spectera/ Care at 800/ 580-8771 for preauthorization.

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

Not covered:
Orthopedic and corrective shoes
Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other supportive devices

All charges

Durable medical equipment (DME)
Durable medical equipment (DME) is equipment and supplies that:
1) Are prescribed by your attending physician (i. e., the physician who is
treating your illness or injury)
2) Are medically necessary
3) Are primarily and customarily used only for a medical purpose
4) Are generally useful only to a person with an illness or injury
5) Are designed for prolonged use; and
6) Serve a specific therapeutic purpose in the treatment of an illness or
injury
We cover rental or purchase, at our option, including repair and adjustment,
of durable medical equipment, such as oxygen and dialysis equipment.

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

Durable medical equipment (DME) benefits continued on next page 29.
29 Page 30 31
2003 APWU Health Plan 27 Section 5( a)
HIGH OPTION
Durable medical equipment (DME) (continued) You pay
Under this benefit, we also cover equipment such as:
Hospital beds
Wheelchairs
Ostomy supplies (including supplies purchased at a pharmacy)
Crutches; and
Walkers

Note: Call Spectera/ Care at 800/ 580-8771 as soon as your physician
prescribes this equipment because prior approval is required. We arrange
with a health care provider to rent or sell you durable medical equipment
at discounted rates and will tell you more about this service when you
call.

(see above)

Not covered:
Whirlpool equipment
Sun and heat lamps
Light boxes
Heating pads
Exercise devices
Stair glides
Elevators
Air Purifiers
Computer "story boards", "light talkers", or other communication aids for communication-impaired individuals

All charges

Home health services
Services for skilled nursing care up to 25 visits per calendar year, not to
exceed a maximum plan payment of $90 per day, when preauthorized and:

A registered nurse (R. N.), licensed practical nurse (L. P. N.) or licensed vocational nurse (L. V. N.) provides the services

The attending physician orders the care
The physician identifies the specific professional skills required by the patient and the medical necessity for skilled services; and

The physician indicates the length of time the services are needed
Note: Skilled nursing care must be preauthorized. Call Spectera/ Care at
800/ 580-8771 for preauthorization.

PPO: 10%; all charges after we pay $90 per
day

Non-PPO: 30%; all charges after we pay $90 per day

Not covered:
Nursing care requested by, or for the convenience of, the patient or the patient's family

Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or
rehabilitative
Nursing services without preauthorization
Services of nurses aides or home health aides

All charges 30.
30 Page 31 32

2003 APWU Health Plan 28 Section 5( a)
HIGH OPTION
Chiropractic You pay
Chiropractic treatment limited to 12 visits and/ or manipulations per year. PPO: $15 copayment (No deductible)
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

Alternative treatments
Acupuncture by a doctor of medicine or osteopathy PPO: $15 copayment (No deductible)
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

Not covered:
Services of any provider not listed as covered; see Covered providers on page 10

Note: Benefits of certain alternative treatment providers may be covered
in medically underserved areas; see page 10

All charges

Educational classes and programs
Coverage is limited to:
Smoking Cessation Up to $100 for one smoking cessation program per member per lifetime.
PPO: Nothing
Non-PPO: Nothing 31.
31 Page 32 33

2003 APWU Health Plan 29 Section 5( b)
HIGH OPTION
Section 5 (b). Surgical and anesthesia services provided by physicians
and other health care professionals

I M
P O
R T
A N
T

When you use a PPO hospital, keep in mind that the professionals who provide services to you in the hospital, such as radiologists, emergency room physicians, anesthesiologists, and
pathologists, may not all be preferred providers. If they are not, they will be paid by this Plan as
non-PPO providers.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section

10 about coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the facility

(i. e. hospital, surgical center, etc.).
YOU MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services

require precertification.
Precertification/ preauthorization is required for:
-Organ transplantations
-Procedures which might be cosmetic in nature, such as eyelid surgery or varicose vein surgery
-Surgery for morbid obesity, or
-Surgery for organic impotence

I M
P O
R T
A N
T

Benefit Description You Pay After the calendar year deductible
NOTE: The calendar year deductible applies to almost all benefits in this Section. We say "( No deductible)" when it does not
apply.

Surgical procedures

A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Electroconvulsive therapy
Removal of tumors and cysts
Correction of congenital anomalies (see Reconstructive surgery)
Surgical treatment of morbid obesity

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

Surgical procedures benefits continued on next page 32.
32 Page 33 34

2003 APWU Health Plan 30 Section 5( b)
HIGH OPTION
Surgical procedures (continued) You Pay
Insertion of internal prosthetic devices. See Section 5( a) for Orthopedic and prosthetic devices for device coverage information

Voluntary sterilization (e. g., Tubal ligation, Vasectomy)
Surgically implanted contraceptives and intrauterine devices (IUDs)
Treatment of burns
Assistant surgeons -We cover up to 20% of our allowance for the surgeon's charge

(see above)

When multiple or bilateral surgical procedures performed during the same operative session add time or complexity to patient care, our
benefits are:
For the primary procedure:
-PPO: 90% of the Plan allowance or
-Non-PPO: 70% of the Plan allowance

For the secondary procedure( s):
-PPO: 90% of one-half of the Plan allowance or
-Non-PPO: 70% of one-half of the Plan allowance

Note: Multiple or bilateral surgical procedures performed through the
same incision are "incidental" to the primary surgery. That is, the
procedure would not add time or complexity to patient care. We do not pay extra for incidental procedures.

PPO: 10% of the Plan allowance for the primary procedure and 10% of one-half of
the Plan allowance for the secondary
procedure( s)

Non-PPO: 30% of the Plan allowance for the
primary procedure and 30% of one-half of
the Plan allowance for the secondary
procedure( s); and any difference between our
payment and the billed amount

Not covered:
Cosmetic surgery and other related expenses if not preauthorized
Reversal of voluntary sterilization
Services of a standby surgeon, except during angioplasty or other high risk procedures when we determine standbys are medically

necessary
Radial keratotomy and other refractive surgery

All charges

Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
-The condition produced a major effect on the member's appearance and

-The condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks (including port wine stains); and webbed fingers
and toes.
All stages of breast reconstruction surgery following a mastectomy, such as:

-Surgery to produce a symmetrical appearance on the other breast
-Treatment of any physical complications, such as lymphedemas

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

Reconstructive surgery benefits continued on next page 33.
33 Page 34 35
2003 APWU Health Plan 31 Section 5( b)
HIGH OPTION
Reconstructive surgery (continued) You Pay
-Breast prostheses; and surgical bras and replacements (see Prosthetic devices for coverage)

Note: We pay for internal breast prostheses as hospital benefits.
Note: If you need a mastectomy, you may choose to have the
procedure performed on an inpatient basis and remain in the hospital
up to 48 hours after the procedure.

(see above)

Not covered:
Cosmetic surgery any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance

through change in bodily form, except repair of accidental injury if
repair is initiated within two years of the accident
Surgeries related to sex transformation, sexual dysfunction or sexual inadequacy except if preauthorized for organic impotence

All charges

Oral and maxillofacial surgery
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones
Surgical correction of cleft lip, cleft plate or severe functional malocclusion

Removal of stones from salivary ducts
Excision of leukoplakia or malignancies
Excision of cysts and incision of abscesses when done as independent procedures

Other surgical procedures that do not involve the teeth or their supporting structures
Extraction of impacted (unerupted) teeth
Alveoplasty, partial ostectomy and radical resection of mandible with bone graft unrelated to tooth structure

Excision of bony cysts of the jaw unrelated to tooth structure
Excision of tori, tumors, and premalignant lesions, and biopsy of hard and soft oral tissues

Reduction of dislocations and excision, manipulation, arthrocentesis, aspiration or injection of temporomandibular joints
Removal of foreign body, skin, subcutaneous alveolar tissue, reaction-producing foreign bodies in the musculoskeletal system and
salivary stones
Incision/ excision of salivary glands and ducts
Repair of traumatic wounds
Sinusotomy, including repair of oroantral and oromaxillary fistula and/ or root recovery

Surgical treatment of trigeminal neuralgia
Frenectomy or frenotomy, skin graft or vestibuloplasty-stomatoplasty unrelated to periodontal disease

Incision and drainage of cellulitis unrelated to tooth structure
Note: We suggest you call us at 800/ 222-APWU to determine whether a
procedure is covered.

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

Oral and maxillofacial surgery benefits continued on next page 34.
34 Page 35 36
2003 APWU Health Plan 32 Section 5( b)
HIGH OPTION
Oral and maxillofacial surgery (continued) You pay
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva and alveolar bone)

Dental bridges, replacement of natural teeth, dental/ orthodontic/ temporomandibular joint dysfunction appliances
and any related expenses
Treatment of periodontal disease and gingival tissues, and abscesses
Charges related to orthodontic treatment

All charges

Organ/ tissue transplants
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single only for the following end-stage pulmonary diseases: pulmonary fibrosis, primary pulmonary hypertension, or

emphysema; Double only for patients with cystic fibrosis
Pancreas
Allogeneic bone marrow transplants are limited to patients with leukemia, advanced Hodgkin's lymphoma, advanced non-Hodgkin's

lymphoma, aplastic anemia, severe combined immuno-deficiency
disease or Wiskott-Aldrich syndrome
Autologous bone marrow transplants and autologous peripheral stem cell support are limited to patients with acute leukemia in remission,

relapsed non-Hodgkin's lymphomas responding to treatment,
resistant or recurrent neuroblastoma, relapsed Hodgkin's disease
responding to treatment, testicular cancer, mediastinal cancer,
retroperitoneal cancer, ovarian germ cell tumors, epithelial ovarian
cancer, breast cancer and multiple myeloma
Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver,

stomach, and pancreas only for those patients with irreversible
intestinal failure who have failed TPN (total parenteral nutrition)

The Plan uses specific Plan-designated organ/ tissue transplant facilities.
Before your initial evaluation as a potential candidate for a transplant
procedure, you or your doctor must contact Spectera/ Care at 800/ 580-8771
and ask to speak to a Transplant Case Manager. You will be provided with
information about transplant preferred providers. If you choose a Plan-designated
transplant facility, you may receive prior approval for travel and
lodging costs.

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount and any amount over
$100,000

Organ/ tissue transplant benefits continued on next page 35.
35 Page 36 37
2003 APWU Health Plan 33 Section 5( b)
HIGH OPTION
Organ/ tissue transplants (continued) You pay
Limited Benefits If you don't use a Plan-designated transplant facility,
benefits for pretransplant evaluation, organ procurement, inpatient hospital,
surgical and medical expenses for covered transplants, whether incurred by
the recipient or donor, are limited to a maximum of $100,000 for each listed
transplant, including multiple organ transplants.

Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount and any amount over
$100,000

Not covered:
Donor screening tests and donor search expenses, except those performed for the actual donor

Services or supplies for, or related to, surgical transplant procedures for artificial or human organ transplants not listed as
specifically covered. Related services include administration of high
dose chemotherapy when supported by autologous bone marrow
transplant
Transplants not listed as covered

All charges

Anesthesia
Professional services for administration of anesthesia PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and the
billed amount

Note: If your PPO provider uses a non-PPO
anesthesiologist, we will pay non-PPO
benefits for any anesthesia charges. 36.
36 Page 37 38

2003 APWU Health Plan 34 Section 5( c)
HIGH OPTION
Section 5 (c). Services provided by a hospital or other facility,
and ambulance services

I M
P O
R T
A N
T

In this Section, unlike Sections 5( a) and 5( b), the calendar year deductible applies to only a few benefits. In that case, we added "( calendar year deductible applies)." The calendar year
deductible is; PPO -$275 per person ($ 550 per family); Non-PPO -$350 per person ($ 700 per
family).

The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

When you use a PPO hospital, keep in mind that the professionals who provide services to you in the hospital, such as radiologists, emergency room physicians, anesthesiologists, and
pathologists, may not all be preferred providers. If they are not, they will be paid by this Plan as
non-PPO providers.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 10

about coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e. hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge

(i. e. physicians, etc.) are in Sections 5( a) or (b).
YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS; FAILURE TO DO SO WILL RESULT IN A MINIMUM $500 PENALTY. Please refer to the precertification

information shown in Section 3 to be sure which services require precertification.

I M
P O
R T
A N
T

Benefit Description You Pay
NOTE: The calendar year deductible applies ONLY when we say below: "( calendar year deductible applies)".
Inpatient hospital
Room and board, such as:
Ward, semiprivate, or intensive care accommodations
General nursing care
Meals and special diets

Note: We only cover a private room when you must be isolated to
prevent contagion. Otherwise, we will pay the hospital's average charge for semiprivate accommodations. If the hospital only has private rooms,

we base our payment on the average semiprivate rate of comparable
hospitals in the area.

Note: When the non-PPO hospital bills a flat rate, we prorate the charges
to determine how to pay them, as follows: 30% room and board and 70%
other charges.

PPO: 10% of the covered charges
Non-PPO: $200 per admission and 30% of
the covered charges

Note: If you use a PPO provider and a PPO
facility, we may still pay non-PPO benefits
if you receive treatment from a radiologist,
pathologist, or anesthesiologist who is not a PPO provider.

Inpatient hospital benefits continued on next page 37.
37 Page 38 39

2003 APWU Health Plan 35 Section 5( c)
HIGH OPTION
Inpatient hospital (continued) You pay
Other hospital services and supplies, such as:

Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services

Note: We cover appliances, medical equipment and medical supplies
provided for take-home use under Section 5( a). We cover prescription drugs
and medicines dispensed for take-home use under Section 5( f).

Note: We base payment on whether the facility or a health care professional
bills for the services or supplies. For example, when the hospital bills for its
nurse anesthetists' services, we pay Hospital benefits and when the
anesthesiologist bills, we pay Surgery benefits.

(see above)

Not covered:
Any part of a hospital admission that is not medically necessary (see definition), such as when you do not need acute hospital inpatient

(overnight) care, but could receive care in some other setting
without adversely affecting your condition or the quality of your
medical care. Note: In this event, we pay benefits for services and
supplies other than room and board and in-hospital physician care
at the level they would have been covered if provided in an
alternative setting
Custodial care; see definition
Non-covered facilities, such as nursing homes, skilled nursing facilities, residential treatment facilities, day and evening care

centers, and schools
Personal comfort items such as radio, television, air conditioners, beauty and barber services, guest meals and beds

Services of a private duty nurse that would normally be provided by hospital nursing staff

All charges 38.
38 Page 39 40
2003 APWU Health Plan 36 Section 5( c)
HIGH OPTION
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures
when necessitated by a non-dental physical impairment. We do not cover
the dental procedures.

Note: We cover outpatient services and supplies of a hospital or free-standing
ambulatory facility the day of a surgical procedure (including
change of cast), hemophilia treatment, hyperalimentation, rabies shots, cast
or suture removal, oral surgery, foot treatment, chemotherapy for treatment
of cancer, and radiation therapy.

PPO: 10% of the Plan allowance (calendar
year deductible applies)

Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount (calendar year deductible
applies)

Extended care benefits/ Skilled nursing care facility
benefits

No benefit All charges

Hospice care
Hospice is a coordinated program of home and inpatient supportive care
for the terminally ill patient and the patient's family provided by a
medically supervised specialized team under the direction of a duly
licensed or certified Hospice Care Program.